Before discussing medical imaging equipment donations in detail, it is important to understand that there are some categories of imaging equipment that should never be donated (MRI), some that require additional, often challenging, infrastructure (digital X-ray and CT), and some that offer a high probability of success with fewer infrastructure considerations (ultrasound, mobile X-ray, and C-arm).

Magnetic resonance imaging (MRI) equipment requires infrastructure that makes it nearly impossible to successfully donate to a resource-poor setting. Most systems will require a regular supply of a difficult-to-obtain (in the developing world) coolant, such as liquid nitrogen. Ready access to high-speed Internet will often be required to conduct maintenance and repair. Both of these are often in limited supply in the developing world. In many cases, maintenance schedules are programmed into the machine, meaning that a service contract is required to keep the machine running, even if there are no repair issues. Electrical power and physical plant infrastructure will often exceed the capabilities of all hospitals outside of the capital, in many developing world nations. In short, donated MRI machines rarely, if ever, function for long enough to substantially benefit the local community.

At the other end of the scale for imaging equipment are ultrasound machines. These machines have become inexpensive and highly reliable. They have been used in highly resource-poor settings such as refugee camps and rural clinics with few problems [5]; however, this is not to say that donations of the equipment are problem-free. The donation of an ultrasound machine involves approximately the same level of complexity, and the same barriers to success, as a bedside monitor or electrosurgery unit [6].

Digital X-ray (including fixed fluoroscopy) and computed tomography (CT) are closer to MRI machines than to ultrasound machines. One of the most often overlooked considerations when donating a digital X-ray or CT machine is the required information technology (IT) infrastructure. In many cases, the device will require temporary or permanent access to the Internet in order to be installed, repaired, and maintained. In most cases, the manufacturer’s representative will be required to install the system. In some cases, the installation and routine maintenance may require a code or software that is only available to technicians who are authorized by the manufacturer. Such authorized technicians may only be available in neighboring or even distant countries, and thus they have to be flown in to help the local facility.

For these reasons, the donation of a digital X-ray, fixed fluoroscope, or CT machine should only be considered when a service contract from a manufacturer’s representative is purchased along with the donation. Since the cost of the service contract will be, by far, the largest cost involved in the donation, and may even exceed the purchase price of used equipment, it rarely makes economic sense to donate a used digital X-ray, fixed fluoroscope, or CT to a resource-poor setting. A donation of a new machine can only be expected to be successful as long as the service contract is maintained.

Stationary, film X-ray, like digital X-ray, will require a special room in the recipient hospital, specialized cabling, and special power considerations. A technician must be flown in from outside the country for both types of installation because the local technician can rarely, if ever, handle the installation of fixed X-ray machines. Of course film and film development chemicals will be required if a digital system is not donated. A film processor may also be part of the donation, though obtaining chemicals for automated film processors can be difficult. However, because there is no IT infrastructure for most film X-ray machines, donations of these machines can be made with a service contract from local providers in most cases. It is sometimes stated that digital X-ray reduces the burden on the developing world because film is not required. However, there is little data to support this statement, and there is ample evidence that the maintenance requirements and adaptation requirements are considerable [7]. Service for a software bug in a digital X-ray machine may be thousands of miles away, making maintenance very difficult.

The most successful X-ray imaging system donations are mobile systems, including C-arms and mobile film-based machines. These machines can often be shipped, be plugged in, and be reasonably expected to work at the recipient hospital. From this perspective, they are like an ultrasound machine. These machines do not require a special room or power to operate. Many newer C-arms and some mobile X-ray machines will require a limited IT infrastructure and annual maintenance visits. So, a service contract is still required or advisable. But, these machines are more common, and therefore manufacturers’ representatives can often be found within the target country.

It must be remembered that medical imaging equipment is first and foremost medical equipment. Therefore, all the considerations for donating medical equipment must also be made when donating medical imaging equipment.

Before considering any donation, the appropriate guidelines should be consulted. A starting spot is the WHO Medical Equipment Donation Guidelines [8, 9]. According to the WHO guidelines, the principles at the core of all medical equipment donations are (1) healthcare equipment donations should benefit the recipient to the maximum extent possible; (2) donations should be given with due respect for the wishes and authority of the recipient and in conformity with government policies and administrative arrangements of the recipient country; (3) there should be no double standard in quality. If the quality of an item is unacceptable in the donor country, it is inappropriate as a donation; and (4) there should be effective communication between the donor and the recipient, with all donations made according to a plan formulated by both parties.

Satisfying all four of these principles is quite challenging, particularly when used medical equipment is being donated. The application of a double standard appears to be the most difficult principle to adhere to. For example, it would certainly be unacceptable to an American physician to be expected to practice with a broken X-ray machine; however, 60 % of hospitals surveyed donate broken medical equipment [10]. No American physician would consider the quality of an expired drug acceptable, yet 90 % of surveyed donors gave expired goods as donations [10].

While the definition of effective communication could be considered vague, there are published checklists and flowcharts that can serve as a base for organizing the communication [11, 12].

As mentioned above, the cost of servicing the donated imaging equipment is the primary driving factor in any donation plan. In the USA, equipment maintenance is the second largest budgetary expense (second only to personnel) in large radiology departments [13]. In the developing world, the personnel costs are typically lower, but the maintenance costs may be an equal or even higher portion of expense. This depends on how often experts must be imported for maintenance and repair, and whether the local staff has the technical expertise to substitute aftermarket parts [14].